Autism Spectrum Disorders

1. AUTISM SPECTRUM DISORDERS:
IDENTIFICATION AND MANAGEMENT
DR NAGENDRA KHATORE, JUNIOR
RESIDENT

2. INTRODUCTION
 Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by
social and communication difficulties, repetitive behaviors, and restricted interests.
 In India, the prevalence rate of autism is 1 in 250, although this figure may vary due
to under-diagnosis.
 It is estimated that 10 million people in India are suffering from autism, making it a
growing concern.

3.  According to the latest data from the Centres for Disease Control and Prevention
(CDC), the prevalence rate of ASD in the United States is 1 in 54.
 The prevalence rate of ASD in Europe is estimated to be around 1 in 100.
 The median prevalence rate is 8.7 in 10,000, but rates tend to be higher in smaller and
more recent studies.

4. CHECKLIST FOR SIGN OF AUTISM :
Social interactions
• Seen to be in their own world
• Show little eye contact
• Not use of gestures
• Not share of enjoyment or
• interests
• Show little emotion or
empathy
• Not respond to their names
• Show not interest to other
children or peers
Communication
• Have little or no babble
• Have little or no spoken
• language
• Not engage in pretend play
• Have echolalia which means
they echo or mimic words or
phrase without meaning or in
an usual tone of voice
• Have difficulty understanding
and following simple
instructions

8. EARLY WARNING SIGNS FOR AUTISM SPECTRUM
DISORDER:
•At 12 months:
•No cooing or reciprocal
babbling
•No use of social gestures
(e.g. waving, pointing to
indicate interest in objects
or people)
•At 18 months:
•No shared enjoyment (e.g.
bringing toys of interest to
show caregivers)
•No meaningful single
words
•At 24 months:
•No spontaneous (non-
echoed) two-word phrases
•No interest in other
children
•At any age:
•Poor eye contact
•No response when name is
called
•Developmental regression;
loss of existing language,
words, or social skills.

9. DEVELOPMENT AND COURSE OF AUTISM
• Autism symptoms are usually identified between 12-24 months of age.
• Onset of symptoms can present as early developmental delays or losses of social or
language skills.
• In some cases, parents or caregivers may describe a gradual or rapid decline in
social behavior or language skills.
• Developmental plateaus or regression can occur, often during the first two years of
life.
• These developmental patterns can result in long-term impairments in social
communication and behavior.

10. • Delayed language development and lack of social interest or unusual social
interactions are common early signs of autism spectrum disorder.
• In the second year, odd and repetitive behaviors and atypical play become more
apparent.
• The clinical diagnosis of autism spectrum disorder is based on the type, frequency,
and intensity of restricted and repetitive behaviors.
• Symptoms are most pronounced in early childhood and early school years, with
some developmental gains typically seen in later childhood.
• Increased interest in social interaction is a possible developmental gain in later
childhood.

11. • A small proportion of individuals with autism spectrum disorder experience
behavioral deterioration during adolescence, while most others improve.
• Individuals with lower levels of impairment may function independently but
may remain socially naive, have difficulty with practical demands, and are
prone to anxiety and depression.
• Only a minority of individuals with autism spectrum disorder live and work
independently in adulthood.

12. PROCESS OF ASSESSMENT

13.  History taking and observation
 Structured tools for screening
 Developmental assessment/IQ assessment
 Assessment of comorbidity, medical conditions
 Past history
 Family history
 If the child has regressed, has fits, consider getting MRI scan and EEG
 Other blood tests and genetic tests may be needed
ASSESSMENT

14.  Developmental assessment divided into following main areas:
 Vision and hearing
 Gross motor
 Fine motor
 Speech- EL, RL
 Social, emotional and cognitive
 Self care/ADL
 Sensory profile/Repetitive behaviour
DEVELOPMENTAL DOMAINS

15. GENERAL PHYSICAL EXAMINATION
 Height, weight, HC
 Dysmorphism
 Neuro-cutaneous markers
 General and systemic examination

16. INVESTIGATIONS
 First line
 Hearing and Vision test
 Thyroid function test
 FBC, Ferritin
 UE
 Chromosomal analysis
 Fragile X
 Creatinine Kinase
 CT/MRI
 The proportion of neuroimaging
abnormalities found in children with global
delay varies widely between 9-80%
 Second line
 Blood -Lactate, Ammonia, Homocystine
 Organic acid, Oligosaccharides,
Glycosaminoglycans for
mucopolysacchiridosis
 Serum oxalates and Transferrins
 EEG

17. MULTIDISCIPLINARY ASSESSMENT AND
EVALUATION IN AUTISM SPECTRUM DISORDER
 Autism Spectrum Disorder (ASD) is a complex disorder that requires a
comprehensive assessment and evaluation approach.
 A multidisciplinary team comprising of a psychiatrist, psychologist, special educator,
occupational therapist, and audiologist and speech therapist is ideal for an accurate
assessment.
 Educational psychologists in school settings can also provide assessment of cognition
and curricular level.

18. ASSESSMENT TOOLS FOR ASD
Screening
 M-CHAT-R (16-30mths)
 Social Com Que (SCQ)
(>4yrs)
 CAST (4-11 yrs)
 SACS-R
 DBCL
Diagnostic
 ADI-R (>2yrs)
 3DI-Developmental, dimensional and diagnostic
interview (from early childhood)
 DISCO-Diagnostic Interview for Social and
Communication Disorders (no restriction)
 ADOS- Autism Diagnostic Observation Schedule
(>1year) (observational)
 CARS (interview and observation)
 Disability and severity assessment-
 ISAA((Indian Scale for Assessment of Autism)
 INCLEN Diagnostic Tool for Autism Spectrum
Disorder (INDT-ASD)

19. ASSESSMENT AND SCREENING TOOLS FOR
AUTISM SPECTRUM DISORDER
 The Ministry of Social Justice and Empowerment (Department of
Empowerment of Disabilities) released the INCLEN Tool for assessment of
Autism Spectrum Disorder in India in 2016.
 The INCLEN Tool includes the Indian Scale for Assessment of Autism, which
provides cut off scores, severity indices, and percentage disability to certify
individuals in accordance with the new Rights of Persons with Disability Act.

20.  The American Academy of Pediatrics recommends screening for developmental
delays and disabilities at 9 months, 18 months, and 24 or 30 months during regular
well-child doctor visits.
 The American Association for Child and Adolescent Psychiatry recommends ASD
surveillance at all developmental and psychiatric assessments of children, ASD
specific screening at 18 and 24 months, or when surveillance raises concern.

21.  Diagnostic evaluation is essential if screening indicates significant ASD
symptomatology. Multi-disciplinary assessment with the clinician coordinating it is
recommended.
 Diagnostic instruments commonly used include ADOS, ADI, and DISCO, but they
only supplement informed clinical judgement.

22. POSSIBLE DIFFERENTIALS:
 Language disorder
 Speech sound disorder
 Social (pragmatic) communication disorder
 Selective mutism
 Attention-deficit/hyperactivity disorder
 Anxiety disorders, particularly social anxiety
disorder
 Major depressive disorder
 Personality disorders
 Stereotypic movement disorder
 Obsessive compulsive disorder
 Tic disorders, including Tourette syndrome
 Intellectual disabilities
 Global developmental delay
 Reactive attachment disorder
 Childhood onset Schizophrenia
 Traumatic brain injury
 Neurobehavioural Disorder
 Prenatal Alcohol Exposure (Fetal alcohol
syndrome)
 Genetic or Metabolic Syndromes

23. COMORBID CONDITIONS IN AUTISM
• 70-80% of individuals with ASD have at least one comorbid condition
• Some of the most commonly reported comorbid conditions in ASD include:
• Attention deficit hyperactivity disorder (ADHD) - prevalence ranges from 30-80%
• Anxiety disorders - prevalence ranges from 11-84%
• Depression - prevalence ranges from 7-76%
• Obsessive-compulsive disorder (OCD) - prevalence ranges from 4-37%
• Eating disorders - prevalence ranges from 3-26%

24. TREATMENT AND MANAGEMENT OF AUTISM
SPECTRUM DISORDER (ASD)
 A multi-sensory, multi-disciplinary approach to treatment is recommended for autism.
 Early intervention is crucial for better outcomes.
 No treatment has yet been found to completely reverse core autistic symptoms.
 Treatments include behavioral, psychosocial, educational, medical, and
complementary approaches.

25.  The choice of treatment options depends on the age and developmental status of the
individual with ASD.
 Chronic management is often required to improve functional independence and
quality of life.
 The focus of management is on minimizing core deficits, promoting socialization,
reducing maladaptive behaviors, and educating and supporting families.

26. PHARMACOLOGICAL MANAGEMENT

27. A TARGET SYMPTOM APPROACH TO
PHARMACOTHERAPY OF AUTISM SPECTRUM
DISORDER (ASD)
 Medication should always be used in conjunction with behavioral interventions and other supportive
therapies
 Target symptoms and medication options:
 Irritability/Aggression: Atypical antipsychotics (risperidone, aripiprazole)
 Hyperactivity/Inattention: Stimulant medications (methylphenidate, amphetamine)
 Repetitive Behaviors: Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline)
 Anxiety: SSRIs (fluoxetine, sertraline), clonazepam
 Sleep Disturbances: Melatonin, clonidine

28.  Medication Dosage and Adverse Effects
1. Irritability/Aggression:
• Risperidone: 0.5-2 mg twice daily; monitor for weight gain, metabolic effects, and
extrapyramidal side effects
• Aripiprazole: 5-10 mg once daily; monitor for weight gain and metabolic effects
2. Hyperactivity/Inattention:
• Methylphenidate: 2.5-30 mg twice daily; monitor for appetite suppression and insomnia
• Amphetamine: 2.5-60 mg daily; monitor for appetite suppression and insomnia

29. 3. Repetitive Behaviors:
• Fluoxetine: 5-40 mg once daily; monitor for gastrointestinal symptoms and agitation
• Sertraline: 25-200 mg once daily; monitor for gastrointestinal symptoms and agitation
4. Anxiety:
• Fluoxetine: 5-40 mg once daily; monitor for sedation, cognitive dulling, and withdrawal effects
• Sertraline: 25-200 mg once daily; monitor for sedation, cognitive dulling, and withdrawal effects
• Clonazepam: 0.25-2 mg twice daily; monitor for sedation, cognitive dulling, and withdrawal effects

30. 5. Sleep Disturbances:
• Melatonin: 0.5-6 mg at bedtime; monitor for daytime sleepiness and headaches
• Clonidine: 0.05-0.2 mg at bedtime; monitor for hypotension and sedation
6. OCD
• SSRIs are often used to treat OCD in both children and adults with ASD.
• Clomipramine, a tricyclic antidepressant, may also be used in certain cases.
• However, there is concern about the potential for increased irritability and aggression in some
individuals with ASD who are taking SSRIs or clomipramine.

31. NON-PHARMACOLOGICAL TREATMENTS

32. STRUCTURED EDUCATIONAL AND
BEHAVIOURAL INTERVENTIONS:
 Early Stage Denver Model (ESDM): An early intervention program for children with
ASD that focuses on improving social communication, play, and imitation skills.
 Applied Behavior Analysis (ABA): A widely used approach that involves breaking
down complex behaviors into smaller steps, and reinforcing desired behaviors while
discouraging unwanted ones.
 SCERTS: A comprehensive educational approach that focuses on enhancing social
communication and emotional regulation, and providing educational supports to help
children with ASD learn and achieve their goals.

33. Developmental interventions:
 DIR/Floortime: An approach that focuses on building emotional connections and
relationships between children with ASD and their caregivers, by following the child's
lead in play and communication.
 Relationship Development Intervention (RDI): An approach that aims to improve
social and emotional functioning by teaching parents and caregivers how to create
meaningful interactions with children with ASD.

34. INTERVENTIONS FOR COMMUNICATION:
 Picture Exchange Communication System (PECS): A visual communication system
that uses picture symbols to help children with ASD express their needs and wants.
 Social Stories: A tool used to help children with ASD understand social situations and
expectations by presenting them in a visual, story-like format.
 Social Skills Training: A program that teaches children with ASD how to interact with
others in a socially appropriate manner.

35. EDUCATIONAL ASSISTANCE:
 TEACCH program: A structured educational program that provides individualized
supports to children with ASD to help them learn and develop skills in a structured
environment.

36. SENSORY INTEGRATION:
 Sensory integration therapy is a type of occupational therapy that helps children with
ASD develop sensory integration skills, by providing activities and exercises that
stimulate and challenge all senses. This can help children with ASD function more
effectively in daily life.

37.  During sensory integration therapy, the child may engage in a variety of activities
designed to stimulate the senses, such as swinging, jumping, climbing, or playing with
different textures or materials.
 The therapist may also use tools such as weighted blankets or brushes to provide input
to the child's sensory system.

38. OTHER INTERVENTIONS FOR INDIVIDUALS WITH
AUTISM SPECTRUM DISORDER (ASD)
 Cognitive Behavioral Therapy (CBT): CBT has shown some evidence of effectiveness
in reducing anxiety and anger management in high functioning youth with ASD.
 This therapy involves working with a trained therapist to identify and challenge
negative thought patterns and behaviors that may be contributing to anxiety or other
emotional difficulties.

39.  Animal-assisted therapy: This therapy involves the use of trained animals, particularly
dogs, to help individuals with ASD improve social skills, empathy, and bonding.
 The non-verbal bond between the individual and the animal can stimulate the release
of oxytocin, which is associated with social bonding and stress reduction.

40.  Introduction of the diagnosis and
implications for the future of the child
 Autism is a neuro-developmental
disability
 It is lifelong
 It starts in utero
 It is not produced by vaccines
 It is not caused by bad parenting
 All children may not be similar
 Early therapy helps
 Education may not be the only aim
 Talk to others about ASD openly
 Talk to other parents of children with
ASD
 The path ahead may be difficult, but
reach out for help at every step of the
way
 Appropriate counseling on genetic issues
COUNSELING FOR PARENTS AND FAMILY
SUPPORT

41. CERTIFICATION
 Certification and insurance Certification is necessary to quantify disability, avail of the
benefits from the various schemes, and qualify for insurance
 Disability assessment should be done using INCLEN tools and Indian Scale for Assessment
of Autism (ISAA), following a clinical diagnosis of ASD using DSM 5 or ICD 10 or other
prevalent criteria
 Various other schemes available to autistic individuals are Niramaya (Insurance), Aspiration
(Early intervention), and GyanPrabha (scholarship)

42. Resources for family members=
Various policies, benefits
Websites , schemes and journals
Workplaces for autism like ‘The Microsoft Autism Hiring Program

43. REFERENCES
 Rutter’s child and adolescent psychiatry 5th edition
 Lewis child and adolescent psychiatry 5th edition
 Kaplan and Saddock’s CTP 10th edition
 Oxford textbook of psychiatry
 DSM- 5 5th edition
 Coomunicationdeall.com
 Josephine Barbaro et al.
 M. Parellada et al.
 Marco Catani et al.

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